Utilization Review Supervisor

St. Francis Medical Center•Lynwood, CA

2d•$37 - $49

About The Position

The Utilization Review Supervisor oversees third-party payer Utilization Review (UR) and denial management processes. The role supervises and coordinates denial management initiatives, including utilization review, authorization appeals, and compliance protocols. It provides direction for the UR process and oversees the analysis, resolution, monitoring, and reporting of clinical denials. The supervisor serves as a liaison among Case Management, the Business Office, and Coding teams to support timely reporting, tracking, and follow-up of denials. The role participates in regular Utilization and Case Management committee meetings with departmental stakeholders and Corporate leadership to provide education and discuss progress and protocols for insurance authorization and denial prevention. The supervisor also conducts ongoing audits, develops process improvement plans for identified deficiencies, and applies knowledge of federal, state, and intermediary guidelines for inpatient acute care and lower levels of care. Other duties may be assigned.

Requirements

Medical graduate, dental graduate, Physician Assistant, or nursing graduate required.
At least one year of experience as a clinical documentation specialist or utilization review coordinator.
Excellent written and verbal communication skills.
Excellent critical thinking skills.

Nice To Haves

ECFMG certification and/or a bachelor's or higher degree from a US-based accredited institution in a Health and Human Services field is highly preferred.
Utilization Review experience is highly preferred.
Denial Management experience is preferred.
At least one year of clinical experience in an acute care setting is preferred.

Responsibilities

Oversee third-party payer Utilization Review and denial management processes.
Supervise and coordinate denial management initiatives, including utilization review, authorization appeals, and compliance protocols.
Provide supervision and direction for the Utilization Review process, including analysis, resolution, monitoring, and reporting of clinical denials.
Serve as a liaison among Case Management, the Business Office, and Coding teams to ensure timely reporting, tracking, and follow-up of denials.
Participate in regular Utilization and Case Management committee meetings with departmental stakeholders and Corporate leadership.
Provide education and discuss progress and protocols for insurance authorization and denial prevention strategies.
Conduct ongoing audits of the Utilization Review and appeal/denial processes.
Develop process improvement plans for identified deficiencies.
Apply knowledge of federal, state, and intermediary guidelines related to inpatient acute care hospitalization and lower levels of care.
Perform other assigned duties.